Fillable APPLICATION FOR CHILD CARE BENEFITS (Licking County Job and Family Services)

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APPLICATION FOR CHILD CARE BENEFITS (Licking County Job and Family Services)

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Ohio Department of Job and Family Services
APPLICATION FOR CHILD CARE BENEFITS
JFS 01138 (Rev. 12/2018)
How do I
apply for
assistance?
• Complete this application, answering as many questions as you can.
• Be sure to sign the application.
• You will see ATTACH PROOF next to questions requiring verification.
(See "What verifications do I need?" for further details).
• A verification checklist will be mailed to you within 10 days of the date the
county agency receives your application if more information is needed to
make a decision on your case.
• You will have 30 days from the date the county agency receives your
application to provide all needed information.
• Turn in the application and verifications to your local county agency.
Office hours may vary by county. Applications and verifications may also
be mailed, faxed, or sent via e-mail.
What
verifications
do I need?
• Proof of Income: Verification of income includes but is not limited to
paystubs, tax records, award letters, child support orders, etc.
• Proof of any child support paid.
• Proof of citizenship or qualified alien status for children in need of
care: If the county agency verifies that you have already provided proof of
citizenship to qualify for OWF, you will not have to provide it a second
time.
• Proof of a qualifying activity for all caretakers in the household:
Verification of a qualifying activity includes but is not limited to an official
school schedule, a work schedule, self-sufficiency contract, etc.
• Provide the name and address of an eligible child care provider for
each child in need of care. (See below for tips on choosing a
provider).
What is
Step Up To
Quality?
Step Up To Quality helps families identify child care programs that go
beyond the minimum standards of licensing. Star rated programs
demonstrate higher levels of quality in a variety of ways. For more
information, visit the ODJFS child care website at
http://jfs.ohio.gov/cdc/index.stm and click on "Step Up To Quality."
How do I
choose a
Child Care
Provider?
• Parents may select any program approved to offer publicly funded child
care. These programs include centers, family child care homes and in-
home aides located throughout the state of Ohio.
• If you would like assistance with selecting a provider, you may contact
your local Child Care Resource and Referral Agency. Visit
http://jfs.ohio.gov/cdc/families.stm for contact information.
• You may use our Child Care Directory to look for programs that fit your
child care needs at http://childcaresearch.ohio.gov. The directory allows
you to search by location, type of program, services offered and days and
hours of operation. Information is provided about each program including
Step Up To Quality rating, any additional accreditation or affiliation,
licensing inspections and substantiated complaints.
Continued on next page
JFS 01138 (Rev. 12/2018)
How do I get
help with
completing
this
application?
• If English is not your primary language: The county agency will
provide someone who can help you understand the questions on this
application.
• If you have a disability, are hearing-impaired or visually-impaired:
The county agency will help you complete this application.
What will I
need to do
after I turn in
my
application?
• If any of the information changes after you turn in this application, you
must provide updates to the county agency.
• Watch for mail from your county agency. Any mail regarding your child
care eligibility will include important information and may require actions
from you.
• Be sure to turn in any required information by the date it is due. Failure
to do so may result in a denial of your application.
• If your application is denied, you may be responsible for payments to
any child care provider whose services have been used since the
submission of the application.
When will my
eligibility
begin?
• Your eligibility for this program is determined within 30 days from the
date the signed and dated application is received by the county agency.
• If this application is approved and you are eligible for child care benefits,
the county agency may authorize payment for child care services from
the date the county agency received this application.
What if my
child has a
disability or I
suspect my
child may be
development
ally delayed?
• To learn more about Medicaid health screenings and early intervention
services for your child, please visit the Ohio Department of Job and
Family Services child care website at
http://jfs.ohio.gov/CDC/childcare.stm and click on "Families."
• Your child care provider may qualify for additional assistance if they
must make special adaptations for your child. Your provider may
contact your county agency for more information.
How do I
make a
complaint
about a
Provider?
If you would like to make a complaint about a suspected violation of
licensing rules, you may call the Child Care Policy Help Desk at 1-877-302-
2347, option 4.
Ohio Department of Job and Family Services
APPLICATION FOR CHILD CARE BENEFITS
JFS 01138 (Rev. 12/2018) Page 1 of 8
1. Voter registration application attached- Assistance Available
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
YES, I want to register to vote. NO, I do not want to register to vote.
If you do not check either box, you will be considered to have
decided not to register to vote at this time.
2. Tell us about you (the applicant)
First Name
Last Name
Date of Birth
Street Address
Check here if you are
homeless. (We will still need a
mailing address)
Mailing Address (if different than street address)
City
County
State
Zip Code
Home Phone Number
( )
Cell Phone Number
( )
May we send text messages to
your cell phone number?
Yes No
Work Phone Number
( )
Email Address
3. Tell us more about you (the applicant)
Are you:
Visually Impaired
Hearing Impaired
Do you need any of the following services?
Interpreter Other: _______________________________________
Sign Language
Marital Status Married Divorced Separated Widowed Not married
Have you, or anyone living with you, ever received cash, child care, food, or medical assistance? Yes No
If yes, who: _______________________________ Where (City/County/State): _________________________
What is your preferred language?
Spoken _________________________________ Written _______________________________
Do you and the people in your home have more than one million total dollars in cash, checking, or savings (such as bank
accounts, annuities, stocks, or bonds)? Yes No
Are you or anyone in your household in the military?
Yes ( Active Duty National Guard/Reserves) No
Have you ever been found guilty of child care
fraud? Yes No
Do you currently have an Ohio Works First (OWF) Self-Sufficiency
Plan? Yes No
If you are a minor, are you currently in LEAP? Yes No
4. Emergency Contact
N/A
First Name
MI
Last Name
Street Address
City
County
State
Zip Code
Home Phone Number
( )
Cell Phone Number
( )
May we send
text messages to
the cell phone
number?
Yes No
Work Phone Number
( )
Email Address
Reset Form
JFS 01138 (Rev. 12/2018) Page 2 of 8
5. Tell us about everyone that lives in your home
You must list everyone who lives with you, even if they are not applying. Please be sure to list your name first. Please include all
household members regardless of the member's need for child care. If you need more space, attach a separate piece of paper.
Name
(First, Last)
Social
Security
Number
Optional
US
Citizen
Y or N
Gender
Date of
Birth
Relation
to you
(spouse,
son, etc)
Race
Hispanic
or Latino
Y or N
Highest Level of
Education Completed
SELF
African
American
Alaska
Native/American
Indian
Asian
Caucasian
Hawaiian/
Pacific Islander
Some High School
HS Diploma/GED
2 Year Degree
4 Year Degree
Masters or Above
Graduation Date:
________________
Number of College
Credit Hours: ______
African
American
Alaska
Native/American
Indian
Asian
Caucasian
Hawaiian/
Pacific Islander
Some High School
HS Diploma/GED
2 Year Degree
4 Year Degree
Masters or Above
Graduation Date:
_________________
Number of College
Credit Hours: ______
African
American
Alaska
Native/American
Indian
Asian
Caucasian
Hawaiian/
Pacific Islander
Some High School
HS Diploma/GED
2 Year Degree
4 Year Degree
Masters or Above
Graduation Date:
__________________
Number of College
Credit Hours: ______
African
American
Alaska
Native/American
Indian
Asian
Caucasian
Hawaiian/
Pacific Islander
Some High School
HS Diploma/GED
2 Year Degree
4 Year Degree
Masters or Above
Graduation Date:
__________________
Number of College
Credit Hours: ______
African
American
Alaska
Native/American
Indian
Asian
Caucasian
Hawaiian/
Pacific Islander
Some High School
HS Diploma/GED
2 Year Degree
4 Year Degree
Masters or Above
Graduation Date:
__________________
Number of College
Credit Hours: ______
African
American
Alaska
Native/American
Indian
Asian
Caucasian
Hawaiian/
Pacific Islander
Some High School
HS Diploma/GED
2 Year Degree
4 Year Degree
Masters or Above
Graduation Date: -
__________________
Number of College
Credit Hours: ______
JFS 01138 (Rev. 12/2018)
Page 3 of 8
6. Tell us about your qualifying activity
If you or the people in your home are working, attending school or participating in a training program, please complete the table below. If
employed, please list your current employer. This includes self-employment and odd jobs. You must ATTACH PROOF of income. If
attending school or a training program, you must provide a current, official schedule. If you need more space, please attach a separate
piece of paper.
Household
Member Name and
Job Title
(if applicable)
Start
Date/End
Date
Employer/School/Training Site Name
Address and Telephone Number
Rate of
Pay
(if
applicable)
How often
Paid
(Weekly,
Bi-weekly,
etc)
Work or School Schedule
(Please check the box next
to the days you work or
attend school. Then list the
hours you work or attend
school on the corresponding
line, ie 8:30 – 5:30)
Name
Sun ______________
Mon ______________
Tues ______________
Wed ______________
Thurs ______________
Fri ______________
Sat ______________
Varies week to week
Address
Telephone No
( )
Schooling – Total credit hours earned:
Name
Sun ______________
Mon ______________
Tues ______________
Wed ______________
Thurs ______________
Fri ______________
Sat ______________
Varies week to week
Address
Telephone No
( )
Schooling – Total credit hours earned:
Name
Sun ______________
Mon ______________
Tues ______________
Wed ______________
Thurs ______________
Fri ______________
Sat ______________
Varies week to week
Address
Telephone No
( )
Schooling – Total credit hours earned:
7. Tell us about your other sources of income.
Other sources of income refer to all the money that you and the people in your home receive such as earnings from child/spousal/medical
support, disability benefits, retirement benefits, Worker's Compensation, Social Security, SSI, Veteran's Benefits, etc. ATTACH PROOF of
all other sources of income.
Do you or does anyone in your household pay Child or Spousal Support? Yes No
If yes, what is your child support obligation per month? ______________ You must ATTACH PROOF of this obligation.
8. Tell us more about the child(ren) who need child care
Child 1
Child's Name (First, Middle, Last)
Child’s Mother’s Maiden Name
Child’s City of Birth
Relationship to Applicant
Child’s Preferred Spoken Language
Is this child a United States citizen or a qualified alien? Yes No
You must provide verification in order to receive child care.
Child's Needs
Does child require protective child care? Yes No
Household Member Name
Type of Income
Amount of Income
(before taxes)
How Often Received
(weekly, monthly, etc)
Date Last Received
JFS 01138 (Rev. 12/2018) Page 4 of 8
Do you have concerns about your child’s growth and development?
Yes No Please describe:
If yes, is there a case plan? Yes No
Is the child enrolled in Head Start? Yes No
If yes, what is the child’s schedule?
From __________________ to __________________
Days/Hours care needed
Sun From ______________ to ______________
Mon From ______________ to ______________
Tues From ______________ to ______________
Wed From ______________ to ______________
Thurs From ______________ to ______________
Fri From ______________ to ______________
Sat From ______________ to ______________
Provider Name and Address
Child 2
Child's Name (First, Middle, Last)
Child’s Mother’s Maiden Name
Child’s City of Birth
Relationship to Applicant
Child’s Preferred Spoken Language
Is this child a United States citizen or a qualified alien? Yes No
You must provide verification in order to receive child care.
Child's Needs
Does child require protective child care? Yes No
If yes, is there a case plan? Yes No
Is the child enrolled in Head Start? Yes No
If yes, what is the child’s schedule?
From __________________ to __________________
Do you have concerns about your child’s growth and development?
Yes No Please describe:
Days/Hours care needed
Sun From ______________ to ______________
Mon From ______________ to ______________
Tues From ______________ to ______________
Wed From ______________ to ______________
Thurs From ______________ to ______________
Fri From ______________ to ______________
Sat From ______________ to ______________
Provider Name and Address
Child 3
Child's Name (First, Middle, Last)
Child’s Mother’s Maiden Name
Child’s City of Birth
Relationship to Applicant
Child’s Preferred Spoken Language
Is this child a United States citizen or a qualified alien? Yes No
You must provide verification in order to receive child care.
Child's Needs
Does child require protective child care? Yes No
If yes, is there a case plan? Yes No
Is the child enrolled in Head Start? Yes No
If yes, what is the child’s schedule?
From __________________ to __________________
Do you have concerns about your child’s growth and development?
Yes No Please describe:
JFS 01138 (Rev. 12/2018) Page 5 of 8
Days/Hours that Child Care is Needed
Sun From ______________ to ______________
Mon From ______________ to ______________
Tues From ______________ to ______________
Wed From ______________ to ______________
Thurs From ______________ to ______________
Fri From ______________ to ______________
Sat From ______________ to ______________
Provider Name and Address
Child 4
Child's Name (First, Middle, Last)
Child's Mother's Maiden Name
Child's City of Birth
Relationship to applicant
Child's preferred spoken language
Is this child a United States citizen or a qualified alien? Yes
No
You must provide verification in order to receive child care.
Child's Needs
Does child require protective child care? Yes No
If yes, is there a case plan? Yes No
Is the child enrolled in Head Start? Yes No
If yes, what is the child’s schedule?
From __________________ to __________________
Do you have concerns about your child’s growth and development?
Yes No Please describe:
Days/Hours that Child Care is Needed
Sun From ______________ to ______________
Mon From ______________ to ______________
Tues From ______________ to ______________
Wed From ______________ to ______________
Thurs From ______________ to ______________
Fri From ______________ to ______________
Sat From ______________ to ______________
Provider Name and Address
9. Tell us about the school attendance of the child(ren) who need care.
If any child(ren) are attending or will be attending Kindergarten or above, this section must be completed.
Child’s Name
Child Entering
Kindergarten
Current
Grade
Level
Name and Address of School
Hours
of
School
(ie 8 am
– 3 pm)
School
Year Start
and End
Date
Will the child be
entering K this year?
Yes No
Kindergarten
Schedule
AM PM
Full Day
Will the child be
entering K this year?
Yes No
Kindergarten
Schedule
AM PM
Full Day
Will the child be
entering K this year?
Yes No
Kindergarten
Schedule
AM PM
Full Day
JFS 01138 (Rev. 12/2018)
Page 6 of 8
10. Rights and Responsibilities
I understand that this application will be considered without regard to race, color, ancestry, sex, age, handicap, religion or national origin. To
the best of my knowledge and belief, the answers on this application are complete and correct. I understand that the law provides penalty of
fine or imprisonment, or both, for anyone convicted of accepting assistance for which he or she is not eligible. I state under penalty of perjury
that all information is true and complete to the best of my knowledge.
By signing and submitting the application, I acknowledge and agree that the county agency and ODJFS may share certain details about the
status of my application with the child care provider listed in section 8 of this application and any amendment thereto, as well as to any child
care provider who I authorize to receive information regarding my application.
My signature below gives my consent to the county agency and ODJFS to make contacts that are necessary to determine my eligibility for
assistance and to verify the information I have given in this application. I understand that my signature below gives the county agency
permission to access available information in the Support Enforcement Tracking System (SETS) to verify my child / spousal / medical
support income. My signature also gives consent to issue a system generated statewide student identifier (SSID) for each child listed in
section 8 of this application.
My signature below gives my consent and authorizes the county agency to access CRIS-E or the Ohio Benefits Worker Portal for the
purpose of verifying the citizenship status of the children in this case and for verification of the receipt of additional public assistance. I may
revoke this authorization at any time by notifying the county agency in writing.
I understand that I will be able to use publicly funded child care benefits only for children who are eligible and only up to the maximum hours
authorized by the county agency. To remain eligible for publicly funded child care benefits, the required copayment (if applicable) must be paid
by me to the provider. Failure to pay the required copayment may result in termination of publicly funded child care benefits.
I understand that I must report any changes which affect my child care eligibility to the county agency, including changes in family income,
hours of employment/training/education, family size and address. I understand that I must report changes within 10 days of the date they
occur.
I understand that if I am approved, I will be responsible for accurately recording my child's attendance at the child care program by utilizing
an automated attendance tracking system. This includes registering in the system and creating personal identification information that I will
use to access the system and to serve as my electronic signature. I understand that my child care provider is not permitted to record my
child's attendance on my behalf, and may not have access to my personal identification information. I understand that the attendance
tracking system may take my photo or a photo of my designee/sponsor as part of the login and logout process. I understand that I am
responsible for approving any changes that my provider makes in the attendance tracking system regarding my child's attendance at the
program.
I understand that if my child attends a Step Up To Quality rated program, and if an assessment is completed on my child, the data will be
collected and reported to ODJFS.
I have received an explanation regarding the requirements for determining eligibility, the reasons why I may not be eligible, my right to a
state hearing, my responsibility for reporting changes to the county agency and the penalty, including possible civil action or criminal
prosecution, for the intentional withholding or falsification of information or misuse of child care benefits, including misuse of the automated
child care attendance tracking system.
Child care fraud is the willful withholding or falsification of information or misuse of child care services as determined by a court of law.
Failure to meet reporting requirements may be considered fraud and may result in the following: 1) repayment of child care benefits which
you received but for which you were not eligible; 2) termination or denial of child care benefits; or 3) penalty of fine and/or imprisonment if
convicted of fraudulently receiving child care benefits for which you were not eligible.
Signature of Applicant
Signature of person who helped you
complete this application (if applicable)
Date
JFS 01138 (Rev. 12/2018)
Page 7 of 8
Your civil rights
Federal law and the policies of the U.S. Department of Health and Human Services (HHS) and the Ohio Department of Job and Family
Services (ODJFS) and the local County Department of Job & Family Services (CDJFS) say that we must not discriminate on the basis of
race, color, national origin, sex, age, or disability. To file a discrimination complaint, write or call HHS or ODJFS. HHS, and ODJFS are
equal opportunity providers and employers.
Write
or
Call:
HHS
Region V, Office of Civil Rights
233 N. Michigan Ave, Ste. 240
Chicago, IL 60601
(312) 886-2359 (voice)
(312) 353-5693 (TDD)
(312) 886-1807 (fax)
Write
or
Call:
ODJFS
Bureau of Civil Rights
30 E. Broad St., 37
th
Floor
Columbus, OH 43215-3414
(614) 644-2703 (voice) or 1-866-227-6353 (toll free)
(614) 995-9961 (TTY) or 1-866-221-6700 (toll free TTY)
(614) 752-6381 (fax)
EXPLANATION OF STATE HEARING PROCEDURES
What is a state hearing?
If you think there has been a mistake or delay on your child care case, you may ask for a hearing by either contacting the
local county department of Job and Family Services (CDJFS) or the state department of Job and Family Services (ODJFS).
A state hearing is a meeting with you, someone from the CDJFS and a hearing officer from ODJFS. The person from the
CDJFS will explain the action it has taken or wants to take on your case. Then you will have a chance to tell why you think it
is wrong. The hearing officer will listen to you and to the CDJFS and may ask questions to help bring out all the facts. The
hearing officer will review the facts presented and recommend a decision based on whether or not the child care rules were
correctly applied in your case.
How do I ask for a hearing?
To ask for a hearing, call or write your CDJFS or write to ODJFS, Bureau of State Hearings, P.O. Box 182825, Columbus,
Ohio 43218-2825. If you receive a notice denying, reducing or stopping your child care, fill out that form and mail it to the
Bureau of State Hearings. You may also fax your hearing request to (614) 728-9574. ODJFS must receive your hearing
request within 90 days of the mailing date of the notice of action. If someone else makes a written request for you, it must
include a written statement, signed by you, telling us that person is your representative. Only you can make a hearing request
by telephone.
How do I request a telephone hearing?
If you cannot attend the hearing at the scheduled location because you do not have transportation or child care or you have
medical limitations, etc., you can call 1-866-635-3748 and participate by telephone. If you participate by telephone the hearing
officer will call you on the day at the scheduled time for your hearing at the telephone number you provide.
Will my child care benefits continue?
If you receive a notice that your child care will be reduced, stopped or restricted, the action will not be taken until the hearing
is decided if we receive your hearing request within the 15 days of the mailing date on the notice. If your child care benefits
have been changed without written notice or if the change was made even though you requested a timely hearing, you can
call the Bureau of State Hearings to ask if you should receive continuing benefits. Call 1-866-635-3748 and choose option
number 1 from the automated voice menu. If your assistance is continuing and you lose the hearing, you may have to pay
back any benefits that you were not eligible to receive.
What is a county conference?
An informal meeting with a person from the CDJFS may settle the issue without the need for a state hearing. This is often
the quickest way to solve a problem. At this meeting, someone will review your case with you. If a mistake was made, it can
be corrected without the need for a state hearing. You can set up a county conference by asking your worker. If you are not
satisfied with the results, you can still have a state hearing. You do not have to have a county conference to have a state
hearing and asking for a county conference will not delay your state hearing.
When will the hearing be held?
The Bureau of State Hearings will send you a notice giving the date, time and place of the hearing. This notice will be sent to
you at least 10 days before the hearing. The notice also will tell you what to do if you cannot come to the hearing as
scheduled. Hearings are usually held at the CDJFS. If you are unable to go there, the hearing may be held some other
place convenient to you and to the other people involved. If you want the hearing held somewhere other than the CDJFS,
be sure to state that on your hearing request.
Can a hearing be postponed?
If you cannot come to the hearing as scheduled or if you need more time to prepare, you can ask for a postponement. You
must have a good reason to postpone the hearing.
JFS 01138 (Rev. 12/2018)
Page 8 of 8
What happens if I do not attend the hearing?
The Bureau of State Hearings will send you a dismissal notice if you do not come to the hearing. If you want to continue with
your hearing request, you must contact State Hearings within 10 days and explain why you did not come to the hearing. The
hearing authority will decide whether you had a good reason. If you do not call within 10 days and show good cause, the
hearing will be dismissed and you will lose the hearing. The CDJFS can then take the action it was planning to take. If you
disagree with the dismissal, the dismissal notice will tell you how to ask for an administrative appeal.
What happens before the hearing?
You may have someone (lawyer, welfare rights person, friend or relative) go to the hearing to present your case for you. If
you are not going to be at the hearing, the person attending for you must bring a written statement from you saying he or she
is your representative. If you want legal help at the hearing, you must make arrangements before the hearing. Contact your
local Legal Aid program to see if you qualify for free help. If you do not know how to reach your Legal Aid, call 1-800-589-
5888 (toll-free). If you want notice of the hearing sent to your lawyer, you must give the lawyer’s name and address to the
hearing authority. You and your representative have the right to look at your case file and the written rules being applied to
your case. You can get a free copy of any case record documents that are related to your hearing request. Any person acting
for you must provide a signed statement from you before looking at your case record or getting copies of case record
documents. The CDJFS does not have to show you confidential records such as names of people who have given information
against you, records of criminal proceedings and certain medical records. Confidential records, which you could not look at
or question, cannot be presented at the hearing or be used by the hearing officer in reaching a decision.
Can I subpoena information?
You can ask the hearing authority to subpoena documents or witnesses that would not otherwise be available and that are
essential to your case. You must request the subpoena at least five calendar days before the date of the hearing and provide
the name and the address of the person or document you want subpoenaed.
What happens at the hearing?
You may bring witnesses, friends, relatives or your lawyer to help present your case. The hearing officer may limit the number
of witnesses allowed in the hearing at any one time if there is not enough room. You and your representative will have the
right to look at the evidence used at the hearing, present your side of the case without undue interference, ask questions and
bring papers or other evidence to support your case. The hearing will be recorded by the hearing officer so that the facts are
taken down correctly. The hearing officer will listen to both sides but will not make a decision at the hearing. Instead, you will
receive a written decision in the mail, issued by the hearing authority. After the hearing decision is issued you can get a free
copy of the recording by contacting the Bureau of State Hearings.
What is a group hearing?
The hearings office may combine several individual hearing requests into a single group hearing, but only if there is no
disagreement about the facts of each case and all involve related issues of state or federal law or county policy. The notice to
schedule your hearing will tell you if you are scheduled for a group hearing. You and your representative will be allowed to
present your own case individually and you will have the same rights at a group hearing as you would at an individual hearing.
What happens after the hearing?
You should receive a hearing decision within 90 days of your hearing request. If you disagree with the hearing decision, your
written decision will tell you how to ask for an administrative appeal.
When will compliance with the hearing decision happen?
The CDJFS must take the action ordered by the decision within 15 days of the date the decision is issued but always within
90 days of your hearing request. Contact the Bureau of State Hearings if you have not promptly received the benefits awarded
by the hearing decision.
Does another action require another hearing?
If you receive another notice that says the CDJFS wants to change your child care benefits while you are waiting for a
hearing or decision, you must ask for another hearing if you disagree with the new action. Remember, the fact that you are
waiting for a hearing or decision will not stop another action from being taken on your case. You must ask for another
hearing on the new action.
Voter Registration and Information Update Form
Please read instructions carefully. Please type or print clearly with blue or black ink.
For further information, you may consult the Secretary of State’s website at: www.OhioSecretaryofState.gov or call (877) 767-6446.
Eligibility
You are qualified to register to vote in Ohio if you meet all the
following requirements:
1. You are a citizen of the United States.
2. You will be at least 18 years old on or before the day of the
general election.
3. You will be a resident of Ohio for at least 30 days
immediately before the election in which you want to vote.
4. You are not incarcerated (in jail or in prison) for a felony
conviction.
5. You have not been declared incompetent for voting
purposes by a probate court.
6. You have not been permanently disenfranchised for
violations of election laws.
Use this form to register to vote or to update your current Ohio
registration if you have changed your address or name.
NOTICE: This form must be received or postmarked by the 30th day
before an election at which you intend to vote. You will be notified by
your county board of elections of the location where you vote. If you
do not receive a notice following timely submission of this form,
please contact your county board of elections.
Numbers 1 and 2 below are required by law. You must answer
both of the questions for your registration to be processed.
Registering in Person
If you have a current valid Ohio driver’s license, you must provide that
number on line 10. If you do not have an Ohio driver’s license, you
must provide the last four digits of your Social Security number on
line 10. If you have neither, please write “None.”
Registering by Mail
If you register by mail and do not provide either an Ohio driver’s
license number or the last four digits of your Social Security number,
you must enclose with your application a copy of one of the following
forms of identification:
Current and valid photo identification, a military identification, or a
current (within the last 12 months) utility bill, bank statement,
government check, paycheck, or government document (other than
a notice of voter registration mailed by a board of elections) that
shows the voter’s name and current address.
Residency Requirements
Your voting residence is the location that you consider to be a
permanent, not a temporary, residence. Your voting residence is the
place in which your habitation is fixed and to which, whenever you
are absent, you intend to return. If you do not have a fixed place of
habitation, but you are a consistent or regular inhabitant of a shelter
or other location to which you intend to return, you may use that
shelter or other location as your residence for purposes of registering
to vote. If you have questions about your specific residency
circumstances, you may contact your local board of elections for
further information.
Your Signature
In the area below the arrow in Box 14, please write your cursive,
hand-written signature or make your legal mark, taking care that it
does not touch the surrounding lines so when it is digitally imaged by
your county board of elections it can effectively be used to identify
your signature.
Please see information on back of this form to learn how
to obtain an absentee ballot.
WHOEVER COMMITS ELECTION FALSIFICATION IS
GUILTY OF A FELONY OF THE FIFTH DEGREE
Registering as an Ohio voter
Updating my address
Updating my name
I am:
1. Are you a U.S. citizen?
Yes
No
2. Will you be at least 18 years of age on or before the next general election?
Yes
No
If you answered NO to either of the questions, do not complete this form.
3. Last Name
First Name
Middle Name or Initial
Jr., II, etc.
4. House Number and Street (Enter new address if changed) Apt. or Lot # 5. City or Post Office 6. ZIP Code
7. Additional Mailing Address (if necessary)
8. County
(where you live)
9. Birthdate (MM/DD/YYYY) (required)
10. Ohio Driver’s License number OR Last Four
Digits of Social Security number (one form of ID
required to be listed or provided)
11. Phone Number (voluntary)
12. PREVIOUS ADDRESS IF UPDATING CURRENT REGISTRATION - Previous House Number and Street
Previous City or Post Office
Previous
County
Previous
State
13. CHANGE OF NAME ONLY Former Legal Name
Former Signature
14.
I declare under penalty of
election falsification I am a
citizen of the United States,
will have lived in this state
for 30 days immediately
preceding the next election,
and will be at least 18
years of age at the time of
the general election.
Your Signature
Date
(MM/DD/YYYY)
FOR BOARD
USE ONLY
SEC4010 (rev. 4/15)
City, Village, Twp.
Ward
Precinct
School Dist.
Cong. Dist.
Senate Dist.
House Dist.
Adams
Alabama
TO ENSURE YOUR INFORMATION IS RECEIVED,
PLEASE DO THE FOLLOWING:
1. Print this form.
2. Make sure all required fields are complete.
3. Sign and date your form.
4. Fold and insert your form into an envelope.
5. Mail your form to your county board of elections.
For your county board's address please visit
www.OhioSecretaryofState.gov/boards.htm
If you have additional questions, please call the office of the Ohio
Secretary of State at (877) SOS-OHIO (877-767-6446).
HOW TO OBTAIN AN OHIO ABSENTEE BALLOT
You are entitled to vote by absentee ballot in Ohio without providing a reason. Absentee
ballot applications may be obtained from your county board of elections or from the
Secretary of State at: www.OhioSecretaryofState.gov
or by calling (877) 767-6446.
OHIO VOTER IDENTIFICATION REQUIREMENTS
Voters must bring identification to the polls in order to verify identity. Identification may
include current and valid photo identification, a military identification, or a copy of a
current (within the last 12 months) utility bill, bank statement, government check,
paycheck, or other government document (other than a notice of voter registration
mailed by a board of elections) that shows the voter’s name and current address. Voters
who do not provide one of these documents will still be able to vote by providing the last
four digits of the voter’s Social Security number and by casting a provisional ballot
pursuant to R.C. 3505.181. For more information on voter identification requirements,
please consult the Secretary of State’s website at: www.OhioSecretaryofState.gov
or
call (877) 767-6446.
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A
FELONY OF THE FIFTH DEGREE.
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Completed 7 June 2021

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